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This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation Act for the Extraction of Construction Materials <br /> and the Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining <br /> Operations. Any alternation or modification of this form shall result in voiding this form. <br /> Applicant: Hall-Irwin Aggregates, LLC By: <br /> Bret Hall, Manager <br /> Date: 2017 <br /> NOTARY FOR PERMIT APPLICANT <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD ) <br /> The foregoing was acknowledged before me this day of , 2017, by Bret Hall as <br /> Manager of Hall-Irwin Aggregates, LLC, the Applicant. <br /> (seal) Notary Public <br /> My Commission expires: <br /> SIGNATURE OF STRUCTURE OWNER <br /> , <br /> Structure Owner: GAIL& MONTA MCCAULEY Signature: r <br /> Date: �/ � ,.� Title: L�) ' �G <br /> NOTARY FOR STRUCTURE OWNER <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD ) <br /> The foregoing was acknowledged before me this day of , 2017, by <br /> as of <br /> (seal) Notary Public <br /> My Commission expires: <br />